Use and Abuse of POLST Forms Expands

“Physician’s Order for Life-Sustaining Treatment” (POLST) forms were designed as a tool for end-of-life planning. More simple in concept than an advance health care directive, durable power of attorney for health care, or living will, the POLST is an order signed by a doctor that goes into immediate effect. Printed on brightly-colored card stock, the POLST is posted prominently in a person’s home and/or in their medical record, as appropriate. If emergency medical personnel are called to a person’s home, they can see at a glance if there is a POLST form and quickly determine whether the person has a do-not-resuscitate order in effect.

As originally conceived (http://www.polst.org/polst-what-it-is-and-what-it-is-not/) , the POLST was to be offered by a doctor to a patient who was seriously, chronically ill, and whose condition was deteriorating to the point where the doctor would not be surprised if he died within a year. Under those circumstances, and particularly where the person was not living in a health care setting, the POLST served to ensure a patient’s end-of-life wishes were respected in the case of an emergency where their advance directive was not readily available.

Both studies and ample anecdotal evidence have shown that frequently in nursing home and other institutional settings, POLSTs are being not suggested but required upon admission, and not just of the seriously ill but of everyone. Not uncommonly, the POLST form is presented to a family member for his or her approval, even when the patient still has legal capacity to make decisions. In the case of a conflict between instructions in advance care planning documents and in a POLST, the latter in time prevails. Thus, an individual who has documented instructions for his care or has appointed a health care proxy who knows his wishes could nonetheless end up having those wishes overruled if a POLST form is approved by another family member and then signed by a physician who may have never seen the patient.

Thus, what was intended as a useful tool for end-of-life planning for a minuscule percentage of the population has been hijacked and is now being used as yet another method of hastening death for the elderly and vulnerable.

Currently, the California Senate is considering expanding the use of POLST forms through two bills, AB 637 and SB 19. AB 637 would authorize nurse practitioners or physician assistants to sign these orders, not only expanding their use but removing a layer of oversight. Under SB 19, a state-wide POLST registry will be created. This means that medical personnel will be able to rely on the registry rather than a physical POLST form. Both of these expansions of POLST bring additional dangers of misuse and abuse of the POLST concept.

Action Item: If you live in California, urge your Senator to vote “no” on SB 19 and your assemblymember to vote “no” on AB 637. Explain that the POLST has morphed into a hazard for patients when they are vulnerable. Until the POLST is brought back to its original purpose, any bill that expands or further institutionalizes it, without additional safeguards, is a step in the wrong direction.